Considering the importance of ‘Communities of Practice’ and Health Promotion Constructs for Upstream Suicide Prevention

Background Suicide is a serious and growing health inequity for Alaska Native (AN) youth (ages 15–24), who experience suicide rates significantly higher than the general U.S. youth population. In low-resourced, remote communities, building on the local and cultural resources found in remote AN communities to increase uptake of prevention behaviors like lethal means reduction, interpersonal support, and postvention can be more effective at preventing suicide than a risk-referral process. This study expands the variables we hypothesize as important for reducing suicide risk and supporting wellbeing. These variables are: 1) perceived suicide prevention self-efficacy, 2) perceived wellness self-efficacy, and 3) developing a ‘community of practice’ (CoP) for prevention/wellness work. Method With a convenience sample (N = 398) of participants (ages 15+) in five remote Alaska Native communities, this study characterizes respondents’ social roles: institutional role if they have a job that includes suicide prevention (e.g. teachers, community health workers) and community role if their primary role is based on family or community positioning (e.g. Elder, parent). The cross-sectional analysis then explores the relationship between respondents’ wellness and prevention self-efficacy and CoP as predictors of their self-reported suicide prevention and wellness promotion behaviors: (1) working together with others (e.g. community initiatives), (2) offering interpersonal support to someone, (3) reducing access to lethal means, and (4) reducing suicide risk for others after a suicide death in the community. Results Community and institutional roles are vital, and analyses detected distinct patterns linking our dependent variables to different preventative behaviors. Findings associated wellness self-efficacy and CoP (but not prevention self-efficacy) with ‘working together’ behaviors, wellness and prevention self-efficacy (but not CoP) with interpersonal supportive behaviors; both prevention self-efficacy and CoP with higher postvention behaviors. Only prevention self-efficacy was associated with lethal means reduction. Conclusions The study widens the scope of suicide prevention. Promising approaches to suicide prevention in rural low-resourced communities include: (1) engaging people in community and institutional roles, (2) developing communities of practice for suicide prevention among different sectors of a community, and (3) broadening the scope of suicide prevention to include wellness promotion as well as suicide prevention.


Introduction
Suicide is a leading cause of death for young people ages 10 through 24 in the United States (1,2).Preventive efforts are especially urgent for American Indian and Alaska Native (AIAN) youth whose elevated rates (1,3) have increased signi cantly in recent years (4).Similarly, rates of suicide in rural areas have increased 1.5 times faster than in urban areas in the United States from 1981 to 2018 (1).In rural America, mental health services are not available to many because of limited access to healthcare generally, mental health provider shortages, and stigma around mental health help-seeking (5,6).For AIAN young people, these factors are likely exacerbated by culturally incongruous care (7).The cultural differences between therapists and the communities they serve can reduce the acceptability and impact of mental health services particularly for suicide prevention for AIAN people (8,9).For communities with histories of systemic injustice, the oppressive practices, such as involuntary inpatient treatment that is linked to suicide interventions, contribute to many not seeking mental health services (10).These issues are particularly relevant in rural locations and in racially and ethnically marginalized communities (11)(12)(13)(14).
With suicide rates highest in rural areas and fastest growing among younger people of color (15)(16)(17) where culturally-responsive mental health services are sparce, there is an urgent need to understand the factors that can contribute to the success of a broad public health approach to suicide prevention.Such an approach includes more than professional mental health services, and builds on the more readily available community, cultural and social resources in rural and diverse communities (e.g., Elders, parents, family members, mentors) to address suicide (18)(19)(20)(21).
A public health approach to suicide prevention engages diverse stakeholders within different community sectors (e.g., law enforcement, schools, religious organizations) and within young people's existing social support networks (22)(23)(24).Such multilevel efforts can include offering interpersonal support to young people, bolstering family support systems, and developing community-level opportunities that promote youth wellbeing and reduce suicide risk.Previous research suggests that such initiatives can be leveraged to create community-based, culturally-and locally-appropriate strategies (18,20,25).
We hypothesize that developing collaborative relationships for suicide prevention and wellness, also described as 'communities of practice' (CoP)(26) can be important for sustainment of suicide prevention strategies, particularly in under-resourced communities.Rooted in social learning theory, CoP are groups of people that cultivate three inter-related elements: shared interest, common community, and practice.Often, people within a CoP represent different perspectives and areas of expertise, and therefore learn about and address complex issues from multiple angles.Thus, CoP can strengthen community helping networks by linking them to institutional services and systems, demystifying or destigmatizing mental health or wellness, and increasing interactions so that connections and care may more easily occur when a young person is struggling but not yet actively suicidal (27).Through engagements in CoP, institutional helpers can connect with communities and families they serve, and get feedback for practicing cultural humility, making their services more locally responsive (28).Social networks of support are an important and often overlooked resource to engage in suicide prevention, particularly in under-resourced communities where institutional services are limited (29).Building CoPs (26,30) is an innovative way to address the complex and culturally-speci c issue of youth suicide prevention.
Through this study, we highlight these two signi cant, often overlooked, aspects of suicide prevention: CoP and health promotion in addition to risk reduction or prevention.Our measured behavioral suicide prevention constructs test whether respondents endorsed participation in "promotion behaviors" (actions done to attain a positive outcome, for example "I talked with someone about how culture can promote youth wellness") and/or in "prevention behaviors" (actions done to avoid a negative outcome, for example: "I helped someone who was down get help").This distinction between "prevention" and "promotion"-oriented behaviors aligns with Regulatory Focus Theory, which posits that people are motivated to pursue goals from these two different orientations, depending on personality and circumstances of an action (31,32).Promotion behaviors for health can generally be done regularly, regardless of circumstances within family and community life.Emergent opportunities to do "prevention" behaviors occur less frequently in daily life because they are predicated on risk detection or observed struggles.Thus, for people in community and family roles such as parents, teachers, coaches, Elders, these behaviors are more challenging to capture over a period of a few months.It is important to include both prevention and promotion in suicide prevention efforts.
Our study assesses how wellness self-e cacy and suicide prevention self-e cacy relate to self-reported preventative behaviors of community members and considers participants' collaborative relationships or CoP.Put differently, our theoretical model includes the social relationships that both enable supportive interactions with people who are suffering, and offer resources and support to enhance and sustain culturallyresponsive practices to enhance mental wellbeing and to intervene to prevent suicidal behavior.
Our cross-sectional survey research from ve Alaska Native (AN) rural and remote communities offers a snapshot of community members' selfperceptions and self-reported behaviors--including suicide prevention and health promotion hereafter referred to as 'preventative behaviors'--to assess the relationships between these key factors.Our analysis also considers the preventative behaviors of people in different kinds of roles within community (family, friends, and Elders) and institutional (behavioral health and mental health counselors, teachers, community health workers) support networks of young people.We have updated our use of the terms "community" instead of "informal" and "institutional" in lieu of "formal" to acknowledge the important ways in which cultural and local protocols structure social relationships, and to re ect language that does not marginalize these social structures of engagement.Our study highlights how survey respondents' self-perceptions and current collaborations support a variety of preventative behaviors.Collaboration across and among these social networks may be important for sustaining suicide prevention and wellness promotion activities, particularly in tight-knit communities.To date, little research considers the role of collaborative relationships in diversifying approaches to suicide prevention to include broad prevention strategies, including wellness promotion, that can be put into practice across multiple community sectors (23,33).

Key Constructs
We describe the connections between the self-perceptions of people in community (family, friends, and Elders) and institutional (counselors, teachers, community health workers) roles, which includes their self-e cacy related to both wellness ('There are things I can do to promote wellness here.')and suicide prevention ('I feel con dent that I can do things to prevent suicide.').Our analysis describes the relationship of these self-perception and CoP constructs (i.e., 'I have many people to work with in my community to prevent suicide.') to participants' self-reported preventative behaviors.
These prevention behaviors re ect actions at the community, family and interpersonal levels.These include community-level actions such as 'working together' to support youth wellness and prevention suicide (e.g., working with a group of people in the community to educate others, such as 'I spoke up about what community organizations can do to reduce the risk of youth suicide.');offering 'interpersonal support' (e.g.encouraging help-seeking for someone who is down, such as 'I reached out to someone who was hurting (alone, sad, angry).');'reducing access to lethal means' (e.g., 'I discussed how to make a home safer (no alcohol, gun safes).');and 'postvention' which involves precautions to reduce the risk of contagion if a suicide should occur (e.g., I shared that it can be harmful to honor someone who died by suicide more than is done for other deaths).These categories of behaviors include universal and selective prevention strategies and are intentionally broad so can be enacted by a variety of people within a young person's institutional and community social network.Notably, our dependent variables include actions taken within families and communities for both universal health promotion (i.e., to support wellbeing) as well as suicide prevention (i.e., done in response to risk) as important behavioral outcomes.

Recruitment Procedures and Sample
We used baseline survey data collected as part of the Promoting Community Conversations About Research to End Suicide (PC CARES) initiative (see Wexler et al., 2016; 2019, or www.pc-cares.orgfor more information on PC CARES).These data were collected in fall 2019 from residents in ve communities in rural, remote Alaska.The 20-minute electronic survey was completed on iPads and included questions about selfperceptions of suicide prevention and wellness self-e cacy, CoP, and preventative actions taken 'within the past few months' both for promoting general wellbeing and buffering risk at times of struggle (suicide prevention via lethal means reduction and postvention, wellness, and supportive interpersonal interactions).
Participants were recruited by posting informational yers in high tra c areas around each community, and by word of mouth.Participants were compensated twenty dollars in cash for completing the survey.Surveys were administered over a period of 1-2 days at central locations in each village (e.g., churches, schools, tribal buildings) by a PC CARES coordinator (BLINDED) who grew up in the participating region.Across the ve communities (population ranging from 193 to 975 inhabitants), 430 people lled out surveys (about 15% of the pooled population across participating villages) with more people recruited in bigger villages.

Steps to Prevention Survey Development
We worked closely with the PC CARES Local Steering Committee (LSC), made up of people who live and work in the rural communities where data collection took place, to develop and adapt our survey.Starting with survey items that showed positive change in the pilot research for PC CARES pilot project between 2014-2016 (34), we worked with our LSC to collaboratively develop new questions and adjust survey items to ensure they t with changes in curriculum, were clear and communicated the intended meaning (35).The adapted "Steps toward Prevention Survey" (StP) was piloted with 100 people in the region to assess understandability, ease of use and preliminary psychometrics.See Table 1 for all items and associated reliability of each subscale.4) Postvention (8 items, all of which focus on prevention actions).There are more promotion items overall, especially for working together and community of practice constructs.We ask respondents to report their behaviors as they relate to the above constructs 'in the last few months'.Actions were rated as binary endorsements (1 = Yes, 0 = No) of a list of suicide prevention and promotion behaviors and summed to form behavior scales in each domain.This process resulted in our nal survey (see Table 1 for items and Cronbach's alpha for each subscale).
Given our focus on developing a community of practice, our study explores the roles held by our participants and how people in various positions in the community perceive their own knowledge and con dence related to prevention and how they interact to do prevention activities.The role distinction was self-selected without exception."High School student" was a role participants could choose on the survey, but for analysis purposes this category was included in the 'no role' category.

Data Analysis
All analyses were conducted using IBM SPSS Statistics (version 28) software (36) for our nal sample of N = 398.
Analyses.Our analysis considers the associations between self-perceptions, community of practice and participants' preventative behaviors.We applied familywise test corrections using the Holm-Bonferroni sequential method to determine the relationship between our independent variables of wellness self-e cacy, suicide prevention self-e cacy and CoP and our dependent behavioral variables: working together, interpersonal support, lethal means reduction and postvention.To estimate the relationship between the self-perceptions and behaviors, each type of behavior was regressed on each self-perception construct to examine independent effects of each self-perception on behavior, while accounting for the effects of other self-perceptions.Using the role categories of participants, we conducted one-way ANOVAs and pairwise posthoc tests to examine if there were differences in each of our measures of self-perceptions and actions between participants who held different types of roles in the community.The Holm-Bonferroni sequential method was used to correct for family-wise error for each association tested on the four behavioral outcomes, as behavior construct outcomes were correlated measures (37).

Descriptive and Exploratory Analysis
An analytic N = 398 participants with complete data on all independent (predictor) and dependent (outcome) variables was used for all analyses.Of these 398 respondents, 182 were aged 15-29.We over-sampled young people since they represent the highest risk age group in Alaska (38, 39).Our sample had the following role groupings: those with unde ned roles and high school students (n = 120, 30%), community role only (n = 211, 53%), institutional role only (n = 25, 6%), or both institutional and community roles (n = 42, 11%).Descriptive statistics and bivariate Pearson correlations among study variables for each of the composites are provided in Table 2.Note that all variables were signi cantly and positively correlated with one another.For example, participants who rated their wellness self-e cacy higher also tended to endorse higher ratings of perceived self-e cacy around suicide prevention.No signi cant pairwise differences were found for any other role comparison aside from the three outlined above.The pattern of these results remains the same even after controlling for role differences.
We examined differences in all study variables by participants' social roles: institutional role (e.g.behavioral health and mental health counselors, teachers, community health workers) (n = 25, 6%), community role (e.g., parent, Elder,) (n = 211, 53%), those who endorsed both institutional and community roles (e.g., both parent and community health worker, n = 42, 11%), and those who reported holding neither institutional or community roles (e.g.not currently employed, high school students, younger people not yet parents) (n = 120, 30%).Groups were compared using one-way ANOVAs, with follow-up pairwise comparisons performed with no familywise correction to explore potential role differences in our study variables.
For the self-perception variables, a signi cant group difference was found for wellness self-e cacy.Those endorsing institutional or community roles (or both) had signi cantly higher ratings of wellness self-e cacy than those not endorsing these roles.For the behavior composites, those endorsing a community and/or institutional role were more likely to work together with others to prevent suicide and promote health and to offer interpersonal support to others.Those with an unde ned role (did not select one) were less likely to take action to reduce someone's access to lethal means as compared with those with who selected a community and/or institutional role.Pairwise follow-up comparisons indicated that those endorsing no institutional or community roles reported engaging in signi cantly fewer prevention and wellness behaviors compared with other groups.The analysis found no other signi cant differences between roles, including tests to control for age and gender.Table 3 provides means on each subscale by role group and includes relevant statistics from the ANOVAs.
To test our hypotheses linking self-perceptions to self-reported behavior, we conducted a separate multiple linear regression for each behavioral outcome construct (Working Together, Interpersonal Support, Lethal Means Reduction, and Postvention) with self-perceptions (Wellness Self-E cacy, Suicide Prevention Self-E cacy, and CoP) as simultaneous predictors.Results indicated distinct patterns of association of selfperceptions to behavior for each behavioral outcome.Higher self-ratings of wellness self-e cacy, as well as having collaborative relationships for suicide prevention or a CoP each were signi cantly and positively associated with the Working Together behavioral construct.Both selfe cacy ratings (prevention and wellness self-e cacy) were statistically signi cant predictors of Interpersonal Support behaviors.The only statistically signi cant predictor of Lethal Means Reduction behaviors was suicide prevention self-e cacy.Finally, both suicide prevention selfe cacy and CoP were signi cant predictors of Postvention behaviors.Taken together, self-perceptions of wellness self-e cacy, prevention selfe cacy and CoP explained a substantial proportion of the variability in suicide prevention and health promotion behaviors, with R 2 values ranging from .17 to .32.Importantly, follow-up analyses controlling for role differences found no signi cant effects for role type on the outcomes after controlling for self-perceptions, and the pattern and strength of results for these associations was consistent with models reported here (results for models controlling for Role available upon request).See Table 3 for statistical results from all multiple regressions.

Discussion
Our study clearly emphasizes the importance of community adult supporters in both institutional and community roles (i.e., people within families and communities outside of institutional roles as well as professionals) as a vital source for enacting suicide prevention and wellness promotion activities within under-resourced Alaska Native communities.This nding is supported by a previous social network analysis describing young AN people's social support networks in remote Alaskan communities where they rely predominantly on family members and peers for support (19).Developing a community of practice to enact a variety of community and family-based suicide prevention and wellness initiatives is novel, and this study provides evidence for this approach.Adult family and community members as well as social service providers (including community health workers, teachers, coaches) are providing a variety of social support to young people.Additionally, our study supports an expanded conception of self-e cacy that includes health promotion as well as suicide risk reduction behaviors (i.e., lethal means reduction, postvention).These points push the eld toward a more expansive approach to suicide prevention that has important implications.
Each will be discussed here.
Often, suicide prevention interventions in the United States ignore the community, cultural and family assets our data clearly show as vital (i.e., those adult supporters endorsing community roles) and relegates people occupying supportive family and community roles (i.e., Elders, parents, aunts, etc.) to positions of 'gatekeepers' who identify and refer vulnerable young persons to mental health care (40,41).The youth suicide prevention eld has devoted time attention to this model (24,40) even though evidence of this strategy's mitigating impact on youth suicidal events is sparce, mixed, and ultimately inconclusive (41)(42)(43).Most importantly, the aim of gatekeeper approaches is to assess individual risk and refer to clinical services, which are not often available in under-resourced communities (5,6) nor are they typically culturallyresponsive for marginalized young people (7).Therefore, while the popular use of gatekeeper training may contribute to suicide prevention, it is not enough on its own; particularly in marginalized, under-resourced, and rural communities where youth suicide is a growing concern.This study provides an expanded perspective.
Our data underscores the importance of strengthening the cultural, community, and family resources that are often more plentiful in rural settings than clinical mental health services or institutional resources.People who identi ed as occupying both community and institutional roles were likely to work together with others to prevent suicide and promote health (Table 2), supporting the notion that both community and institutional systems are important vectors for multidimensional and collaborative suicide prevention actions.This nding highlights the important, often ignored, cultural and community strengths within communities that can be important assets for promoting wellness and preventing suicide before a crisis.Partnering with community and family members-those who are already engaged in the lives of youth-offers a way to strengthen the social safety net that is currently in place in communities.Indeed, such collective efforts may support more sustainable and larger-scale outreach for suicide prevention and health promotion in rural, under-served communities, like the remote AN communities in this study.
Likewise, in our analysis, people who indicated having an existing CoP to work with (i.e., "I have regular opportunities to work with others to increase wellness") were more likely to report taking actions in collaboration with others to address suicide (Table 3).These multidimensional activities included efforts to educate others about protective factors, do wellness activities, participate in postvention planning, and share suicide prevention resources.This nding is consistent with the literature about CoP (26), and illuminates the importance of developing a CoP to facilitate collaborative initiatives (i.e.working together) in many different locally-directed ways to reduce suicide risk and promote overall health.
This clear nding suggests that creating a CoP that supports collaborative suicide prevention activities is a promising and under-utilized avenue for preventative strategies at multiple levels and across the prevention spectrum, especially for rural communities and those with limited institutional resources.
Shifting focus from an individual's perceived self-e cacy to execute narrowly prescribed actions to considering their perceptions about their ability to problem solve and collaborate with others to execute locally directed actions (44) offers an expanded orientation from which to approach suicide prevention.This collective orientation is measured through our CoP independent variable and is associated with both Working Together and Postvention behaviors (see Table 4).The distinct associations include the social support systems for both those at risk of suicide and also for those who are supporting them.In small, tight-knit and under-resourced communities with limited professional helpers and too common suicidal events (39), this social support system for those providing support is clearly important for sustainable action.
Our ndings also elucidate some important distinctions within the idea of self-e cacy for suicide prevention.Self-e cacy is a central component to many social science theories of individual behavior change.It has been incorporated into foundational implementation science frameworks, and is typically de ned as "…an individual's belief in their own abilities to execute [speci c] courses of action…" (45, p. 9), This study includes two dimensions of self-e cacy: wellness and suicide prevention, signifying one's perceived knowledge and skills to do these two types of actions.As discrete yet inter-related concepts, our Wellness Self-E cacy and Prevention Self-E cacy constructs are a novel way to conceptualize these two self-perceptions.Our ndings corroborate previous research that self-e cacy is important, but for different kinds of behavioral outcomes.Both wellness and prevention self-e cacy are associated with offering Interpersonal Support, whereas only wellness selfe cacy is associated with Working Together.Distinctly, prevention self-e cacy is associated with Lethal Means Reduction and Postvention behaviors (see Table 4).Including both wellness promotion and suicide prevention orientations expands our understanding of the kinds of perceptions and resources needed for comprehensive prevention efforts.
These ndings suggest that Regulatory Focus Theory may be an important consideration for suicide prevention, speci cally the implications of promotion versus prevention framing.A wellness promotion orientation expands measurement to include commonplace events (not predicated on crisis or risk), such as listening to or offering opportunities to young people, that can promote wellbeing in an on-going way.A prevention orientation may be more aligned with stopping a rare event.While these Regulatory Focus Theory framings have been shown to impact outcomes in health communication (46,47), and across many other domains including leadership styles (45,48), social support (49), consumer purchasing behaviors (50), and even athletic performance (51), to our knowledge, no work has been done to investigate how Regulatory Focus of prevention and promotion may be important for suicide prevention programs.Further research might explore how and for whom these dimensions-promotion and prevention-may be differently important for uptake of suicide prevention programs.

Limitations
The study reports on cross sectional data from remote and rural AN communities that was collected over several days in the Fall in 2019.
Although the data represents approximately 15% of the population of participating villages, the sample is not representative.We strategically recruited those in the main institutions within communities as well as people employed by institutions like the school or tribal health corporation and oversampled youth.Our survey categorized individuals according to self-reported "community" or "institutional" roles, which may not capture the nuances of how Alaska Native participants see their connections in the social environment.Indeed, 120 (30%) of our participants selected neither institutional nor community roles.This may impact our ndings on role differences across our study constructs (Table 2).
Additionally, the survey analysis relies on self-reported behaviors done over the last few months.Thus, our results offer just a snapshot of community members' self-perceptions and reported suicide prevention and health promotion behaviors.It is likely that the StP survey items neglected more subtle and culturally-based forms of local support as it was limited to the survey's prescribed behaviors.Importantly, the StP Survey measure is a work in process.Our con rmatory factor analysis shows limitations of our binary (Yes/No) behavior outcomes, speci cally related to our three item Lethal Means Reduction subscale.This scale has Cronbach's alpha lower than desired.However imperfect our measure, this evidence-based construct of lethal means reduction (53-55) is a vital way to prevent suicide in communities with household rearms.We continue to work with our community partners to develop a precise and understandable subscale for this critical construct, and because of its importance, include lethal means reduction as a key behavior subscale in our analysis.

Conclusion
Our ndings overall provide foundational information for multidimensional intervention practices that support local people working collaboratively across existing institutional and community systems of care.The cross-sectional study investigates how self-perceptions related to suicide prevention, wellness and collaborative relationships predict suicide prevention and health promotion activities, which include behaviors across the prevention spectrum.Our study found that general support for young people (wellness or health promotion) is important to include alongside targeted suicide prevention outreach.Research suggests both types of approaches contribute to lowering youth suicide risk (56).Given our ndings, we suggest an expansion beyond focusing solely on intervening according to individual risk to include collaborations across sectors through a community of practice to encourage and support suicide prevention and wellness promotion.Moving beyond individual-level approaches to suicide prevention, this study highlights key factors in the social environment that encourage people's engagement in activities to reduce risk and promote wellness.This expanded approach to suicide prevention is especially important for under-resourced, culturally distinct communities. Declarations

Table 1 PC
CARES Steps to Prevention (StP) MeasureOur independent variables are self-reported behaviors: wellness self-e cacy, prevention self-e cacy, and CoP, and were rated on a Likert scale ranging from Strongly Disagree = 1 to Strongly Agree = 7.Each factor composite was calculated as an item average.The StP Survey dependent variables focus on different kinds of suicide preventative activities and are characterized as: (1) Working together to prevent suicide and promote health (8 items which includes 2 wellness and 3 suicide prevention actions, and 3 actions encompassing both), (2) Interpersonal support (7 items, of which 4 focused on wellness promotion, and 3 on suicide prevention actions), (3) Lethal means reduction (3 items, all of which focus on prevention actions), and ( I have regular opportunities to work with others to increase wellness I have many people to work with in my community to prevent suicide BEHAVIORS Work Together to Prevent Suicide and Promote Health I asked someone for help doing prevention/wellness work when I needed it I spoke up about what community organizations can do to reduce the risk of youth suicide α = .841Isuggested ways community organizations could work together to increase wellness I talked with community members about wellness I talked with others about wellness and/or suicide prevention I worked with others to prevent suicide or promote wellness I let people know what resources are available for preventionI worked with a group of people in the community to share suicide prevention information I tried to make a home safer (such as no alcohol, locked guns) when worried about someone living there.α = .498I worked on a community-wide project to make homes safer I discussed how to make a home safer (no alcohol, gun safes)

Table 2
Descriptive Statistics and Correlations for Study Independent and Dependent Variables c Participants endorsing no role differ from those endorsing both institutional & community roles.